ACOs: Better Definitions Needed

As the number of accountable care organizations (ACOs) grows rapidly, carefully defining their target population will improve their maturation and delivery of care, according to two public health experts.

Although ACOs were devised to control healthcare costs, drive quality, and improve population health, their target population remains ill-defined, said Douglas J. Noble, MD, MPH, and Lawrence P. Casalino, MD, PhD, both of Weill Cornell Medical College in New York City, in a Viewpoint article online in JAMA.

"When population health is clearly defined, it becomes possible to think more specifically about what needs to be done to improve it, whether and how ACOs can help, the types of organizations with which ACOs will need to cooperate, and the incentives that ACOs – and other organizations – will need to improve the health of the population in their geographic area," they said.

Most recently, the Affordable Care Act, the Centers for Medicare and Medicaid services (CMS), and ACOs have interpreted "population" as Medicare beneficiaries, the authors said. Other ACOs have employed a medical description of "population health." While laudable, that is insufficient to improve the health within geographic areas, they suggested.

"Talking about ACOs as if they are focusing on improving population health – as opposed to improving medical care for their populations of patients – leads to a lack of clarity about what ACOs are doing and about population health, and may divert attention away from social and public health services and from socioeconomic factors critical to health," Noble and Casalino wrote.

"It would be unfortunate if ACOs ... were to result in a narrowing and medicalization of the phrase 'population health.' "

In addition, a lack of incentives and capabilities impede ACOs' progress, the authors noted. Many ACOs lack experience and authority to be effective in public health.

They cited the 33 metrics for ACOs prescribed by CMS that lack "a clear link to geographic population health," they wrote, noting that an ACO's patients typically comprise only a fraction of the people among the geographic population. Incentives to focus on community health or the long-term health of an ACO's patients are few.

The authors cited a recent University of California Los Angeles report that mapped out versions of how the greater healthcare system should progressively advance, starting with acute reactive medical care (version 1.0) and moving to chronic disease management (version 2.0) and then to medical organizations and public health agencies together focusing on primary preventive health in geographic communities (version 3.0).

The growth of ACOs should strive for version 3.0, they said. But how to incentivize ACOs in that direction is problematic.

Large ACOs have the benefit of relationships with private insurers in addition to Medicare, giving them more opportunities to improve the health of the larger community, the authors pointed out. In addition, some ACOs are based in nonprofit hospitals that must maintain tax-exempt status through abiding by community benefit reporting requirements. Under the Affordable Care Act, those hospitals must address community health needs.

How clearly "population health" is defined will determine the quality of debate about how to achieve it, they argued. "It is not merely a semantic issue, of little importance, if ACOs are described, or self-described, as working to improve population health when what they are really doing is improving medical care for their own patients."

"If the good name of population health continues to be used this way, it will be difficult to understand what ACOs are doing, what tasks they are not doing but should be done, who can do these tasks, how performance on these tasks should be measured, and how and for whom incentives should be created," Noble and Casalino concluded.

Casalino reports receiving honorariums for lectures from Primary Care Summit of the Connecticut Center for Primary Care and Mission Health System, and has agreed to speak this month for the American Medical Group Association, for which he will receive an honorarium. No other disclosures were reported. This research was supported by the Commonwealth Fund, including Noble's Harkness Fellowship. The fund reviewed the manuscript, and made only minor comments.

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